4800-FM-DMO0067M 9/2001COMMONWEALTH OF PENNSYLVANIA

DEPARTMENT OF ENVIRONMENTAL PROTECTION

MINE SUBSIDENCE INSURANCE FUND

25 Technology Drive

Coal Center, PA 15423GIS--NICK

1-800-922-1678

APPLICATION FOR MINE SUBSIDENCE INSURANCE

A SEPARATE APPLICATION IS REQUIRED FOR EACH STRUCTURE

Please print legibly and complete all sections below that apply

NAME(S) THAT APPEAR ON DEED

First MI Last

Social Security #Birthdate

First MI Last

Social Security #Birthdate

COMPANY NAME FIN#

ADDRESS OF STRUCTURE TO BE INSURED

Number Street (Ave., Drive, etc.)

City State Zip

MAILING NAME AND ADDRESS, IF DIFFERENT FROM ABOVE

First MI Last

Number Street (Ave., Drive, etc.)

City State Zip

STRUCTURE INFORMATION

County Municipality

(Township, Borough, City)

Structure Type (Check One):House Detached GarageBarn Commercial Outbuilding

Number of Stories Year Built Primary Residence YesNo

Amount of Insurance Desired $ Estimated Value Of Structure $

Home Telephone Number:

List Below The Best Time And Telephone Number To Call Between 8:00AM - 4:00PM, Monday-Friday

(Best Time)(Number if different from Home #)

Please complete Structure Information on the reverse side

APPLICATION FOR MINE SUBSIDENCE INSURANCE (CONTINUED)

Yes NoIs this structure a complete building? (Must contain a foundation, four walls, and a roof)

If no, Please describe the structure

Yes NoIs any part of this structure used for other than a single family dwelling?

If yes, please explain

Yes NoAre you aware of any damages or other problems with walls, floors, foundations, or other structural components due to past or present movement, shifting, deterioration, etc.?

If yes, please explain

Yes NoAre you aware of any earth movement or stability problems such as sliding, settling, upheaval, mine discharge or mine subsidence that have occurred on or affect yourproperty?

If yes, please explain

Yes NoAre you aware of any earth movement or stability problems such as sliding, settling, upheaval, mine discharge or mine subsidence that occurred to adjacentproperties?

If yes, please explain

Yes NoSince each detached structure requires a separate applicationandpremium, are there any detached structures you would like to insure? If yes, please describe the structure(s).

Do you need an additional application(s) Yes No

From the enclosed “Rate Chart”, have you made a check or money order for the appropriate amount payable to the “Commonwealth of Pa”?

NOTE: It is the sole responsibility of the applicant to determine the need for Mine Subsidence Insurance coverage. Policy premiums will not be refunded except for instances where a policyholder cancels coverage in accordance with the provisions of the Insuring Agreement. Coverage is not effective until the Fund determines the structure meets all eligibility requirements and the premium has been paid. The Fund reserves the right to conduct an inspection of the structure and adjacent grounds either prior to or after coverage is effective with appropriate notification and just cause.

The undersigned represents that the information set forth in this “Application for Mine Subsidence Insurance” is accurate and complete to the best of his/her knowledge.

Signature Date

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